ABSTRACT The purpose of this investigation was to analyse the impact of the availability of highly active antiretroviral therapy (HAART) on the long-term outcome of human immunodeficiency virus (HIV)-infected patients admitted to the intensive care unit (ICU). A retrospective cohort study of HIV-infected patients admitted to the ICU was undertaken. Outcomes in the pre-HAART era (1990-June 1996), early- (July 1996-2002), and recent-HAART (2003-2008) periods and total HAART era (July 1996-2008) were analysed and compared with those reported of the general population. A total of 127 ICU admissions were included. The 1-year mortality decreased from 71% in the pre-HAART era to 50% in the recent-HAART period (p = 0.06). The 5-year mortality decreased from 87% in the pre-HAART era to 59% in the early-HAART period (p = 0.005). Independent predictors of 1-year mortality in the HAART era were age (odds ratio [OR] = 1.16 [95% confidence interval [CI] = 1.06-1.27]), APACHE II score > 20 (6.04 [1.25-29.22]) and mechanical ventilation (40.01 [3.01-532.65]). The 5-year survival after hospitalisation was 80% and in the range of the reported survival of non-HIV-infected patients (83.7%). Predictors of 1-year mortality for HIV patients admitted to the ICU in the HAART era were all non-HIV-related. Short- and long-term outcome has improved since the introduction of HAART and is comparable to the outcome data in non-HIV-infected ICU patients.

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IntroductionThe combination antiretroviral therapy (cART) has led to decreased opportunistic infections and hospital admissions in human immunodeficiency virus (HIV) infected patients; but the intensive care unit (ICU) admission rate remains constant (or even increased in some instances) during the cART era. Hepatitis C virus (HCV) infection is associated with an increased risk for hospital admission and/or mortality (particularly those related to severe liver disease) compared to the general population. The aim of this study was to assess the mortality among HIV-infected patients in ICU, and to evaluate the impact of HIV/HCV coinfection and severe sepsis on ICU mortality.Methods
We carried out a retrospective study based on patients admitted to ICU who were recorded in the Minimum Basic Data Set (2005-2010) in Spain. HIV-infected patients (All-HIV-group (n¿=¿1891)) were divided into two groups: HIV-monoinfected patients (HIV-group (n¿=¿1191)) and HIV/HCV-coinfected patients (HIV/HCV-group (n¿=¿700)). A control group (HIV(-)/HCV(-)) was also included (n¿=¿7496).ResultsAll-HIV-group had higher frequencies of severe sepsis (57.7% vs. 39.4%; p¿<¿0.001) than control group. Overall, ICU mortality in patients with severe sepsis was much more frequent than in patients without severe sepsis (other causes) at days 30 and 90 in HIV-infected patients and control group (p¿<¿0.001). Moreover, all-HIV-group in presence or absence of severe sepsis had a higher percentage of death than control group at days 7 (p¿<¿0.001), 30 (p¿<¿0.001) and 90 (p¿<¿0.001). Besides, HIV/HCV-group had a higher percentage of death both in patients with severe sepsis, and in patients without severe sepsis compared to HIV-group at days 7 (p¿<¿0.001) and 30 (p¿<¿0.001); while no differences were found at day 90. In a Bayesian competing risk model, HIV/HCV-group had higher mortality risk (adjusted hazard ratio (aHR)¿=¿1.44 (95%CI¿=¿1.30-1.59) and aHR¿=¿1.57 (95%CI¿=¿1.38-1.78) for patients with and without severe sepsis, respectively).ConclusionsHIV infection was related to higher frequency of severe sepsis and death among patients admitted to the ICU. Besides, HIV/HCV coinfection contributed to an increased risk of death in both presence and absence of severe sepsis.

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Since the advent of highly active antiretroviral therapy in 1996, we have seen dramatic changes in morbi-mortality rates from human immunodeficiency virus-positive patients. If on the one hand, the immunologic preservation-associated with the use of current antiretroviral therapy markedly diminishes the incidence of opportunistic infections, on the other hand it extended life expectancy of human immunodeficiency virus-infected individuals similarly to the general population. However, the management of critically ill human immunodeficiency virus-infected patients remains challenging and troublesome for practicing clinician. Sepsis – a complex systemic inflammatory syndrome in response to infection – is the second leading cause of intensive care unit admission in both human immunodeficiency virus-infected and uninfected populations. Recent data have emerged describing a substantial burden of sepsis in the infected population, in addition, to a much poorer prognosis in this group. Many factors contribute to this outcome, including specific etiologies, patterns of inflammation, underlying immune dysregulation related to chronic human immunodeficiency virus infection and delays in prompt diagnosis and treatment. This brief review explores the impact of sepsis in the context of human immunodeficiency virus infection, and proposes future directions for better management and prevention of human immunodeficiency virus-associated sepsis.

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We report a case of an adult patient with human immunodeficiency virus (HIV), acute respiratory distress syndrome (ARDS) and ventilator associated pneumonia (VAP) caused by multidrug resistant (MDR) bacteria that was successfully managed with veno-venous extracorporeal membrane oxygenation (ECMO).
A 25 year old male with no significant past medical history had been admitted to a local hospital due to dyspnea and fever. His pulmonary function subsequently failed necessitating mechanical ventilation (MV) and introduction of ECMO support. The patient was transported for 300 km by road on ECMO to a tertiary medical center. The diagnosis of ARDS, HIV infection and MDR bacterial and fungal VAP was made. Patient was successfully treated with antiretroviral therapy (ART), anti-infective agents and 58 days of veno-venous ECMO support, with complete resolution of the respiratory symptoms.
HIV infected patients with ARDS and MDR bacterial VAP whose HIV replication is controlled by ART could be successfully managed with ECMO.

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